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Founded in 1948, Britain’s National Health Service is the largest and oldest single-payer healthcare system in the world and is overseen by the British government’s Department of Health. Since its inception after the Second World War, the NHS has seen a great deal of change. By sharing the experience of two NHS nurses, one trained in the 1940s and another at the beginning of the twenty-first century, Emma Shires reveals how the NHS works, how it has developed over the years and what challenges it faces for the future.
Text: Emma Shires
Country: England

ntroduced by the Labour government in Britain after the Second World War, the National Health Service (NHS) was founded on three main principles: that it meet everyone’s needs, that it be free at the point of delivery and that it be based on need, not the ability to pay. Although the NHS has changed since 1948, these core principles remain, with UK residents able to see a doctor and have hospital treatment free of charge.

Although private healthcare is also available in the UK, the NHS is popular, and most citizens, even those better off, don’t feel the need to sign up to a private healthcare system. My grandfather, for example, now aged 93, was given private healthcare insurance through his work. However, he hardly ever used it, finding that the NHS options were nearly always preferable.

I’m very proud of my country’s health service, like many British citizens who cherish the NHS even more than the monarchy, according to surveys. For example, in a 2013 study nearly three quarters of the population declared the NHS to be “a symbol of what is great about Britain”.

To help tell the story of the NHS through the experiences of those who know it best, its medical staff, I’d like to present two British women whose passion for caring for others led them to choose to train as nurses.

In 1948, the year the NHS was introduced, my grandmother Betty became a trainee nurse at Nottingham City Hospital. She lived on-site in nurses’ quarters with the other trainee nurses, where there were very strict rules enforced by the ward sister, the head nurse. Nurses had to be back in their accommodation by 9:30 p.m. without fail, unless they were working the hospital night shift, and no visitors were allowed. On the ward, the sisters ensured that all the nurses were impeccably dressed, arrived punctually for their shifts and that they used formal terms of address for patients and other medical staff. Training lasted three years, during which time the trainee nurses received a small wage.

Betty qualified in 1951, the same year she got married. During this first stage of her nursing career she continued to work on the ward. Shift work often meant that she didn’t see my grandfather for a few days at a time. He laughs that during this period they communicated by leaving notes for each other in the house, and he would often come home to find one saying that his dinner was in the oven.

After a time she left the ward to work ‘on the district’, which meant she visited patients in their homes, often to help with their recovery after an operation. She said she performed tasks like changing dressings, and added that spending time with patients was extremely important. She felt that she and her colleagues talked to patients more than modern nurses do; nowadays nurses undertake tasks that would have been done by a doctor in her day, such as taking blood tests and administering injections. When my grandmother was working as a nurse for the local coal mine in the 1950s, the first thing she always did when a miner had had an accident was to give him a cigarette. She said that this was widely considered good practice as a way of calming the nerves. That, of course, is not something medical staff would recommend anymore!

Fast forward more than half a century, and another young woman is beginning her nursing training in the UK. In 2006, Rachel left home to study nursing at Southampton University. Just like my grandmother, she studied for three years. However, the training that Rachel received was markedly different. While my grandmother was taught ‘on the ward’ by shadowing the qualified nurses, Rachel’s training was split, half on lectures and half on nursing placements. This helps to explain why modern nurses’ knowledge and tasks includes some areas that were previously reserved for doctors. Rachel explained that before starting university she had to choose what sort of nursing she would like to focus on, such as adult, child or mental health nursing, although there are some options for training in both adult and child nursing.

Rachel said that when she wasn’t on a nursing placement, classes were held Monday to Friday 9a.m. to 5p.m., more or less. When on a placement, the student nurses follow the same shifts as a qualified nurse, which would mean they would sometimes work evenings and weekends. Placements are held both in clinical and community settings and normally last 10 weeks. Over the course of nursing training, students have to do a minimum of 2,300 hours of nursing placements in order to qualify as a nurse; write various essays, including a longer dissertation; and pass written and practical exams.

Having successfully qualified in 2010, Rachel is now working as a Junior Sister on a children’s surgical ward. Her working week is made up of three or four 12and a half hour shifts that might take place during the day or night, just like my grandmother’s did. As a Junior Sister, Rachel has additional responsibilities that include allocating patients to staff at the start of shifts; coordinating ward rounds; working closely with other medical staff to plan and implement care; reviewing and auditing practice on the ward; and mentoring student nurses.

“What I like about being a nurse”, Rachel told me, “is that I get to work very closely with families so I feel like I can really make a difference to someone’s care during a difficult time. I also like that there are always new learning opportunities and that eight years into my career I am still learning new things every day. On the other hand, my least favourite thing about nursing is the fact that the ward is often short-staffed and very busy. I often don’t get more than a half hour break a day, and sometimes it is only a few minutes!”

I told Rachel about my grandmother’s experiences as a nurse at the very birth of the NHS and asked her how she thought that the role had changed. Just as my grandmother said, she explained that nurses are taking on more responsibilities and are now even involved in leading care. As a result, healthcare support workers are taking on some of the tasks that would have traditionally been for nurses, including the more pastoral side that my grandmother so enjoyed. On the ward, nurses normally know more about the patients than the doctors. As a result, there is a team approach to care between doctors and nursing staff, rather than the more hierarchical relationship between doctors and nurses that my grandmother was used to.

There is also now a huge push for medical staff to continue developing, with nurses encouraged to attend various courses and study days. The government has very high standards for medical care, and there are frequent audits and reviews. It’s important that nurses are aware of new medical research and change their practices accordingly. Rachel said that the amount of paperwork has also definitely increased and that means there are a lot more management roles in nursing, and perhaps fewer nurses directly involved in care. Finally, the internet and social media have also had an impact on the medical profession, as families have access to more medical information and thus want to be more involved in decisions about care.

The changes in the nursing profession shown in my grandmother’s and Rachel’s experiences are amazing. However, it’s clear that patient care remains at its heart. As Rachel is still at the start of her career, she will no doubt see further developments. When I asked her what challenges she saw for the NHS, she mentioned the fact that people are now living much longer, thanks to modern healthcare. Longer lives have consequences, such as the fact that more elderly patients have more complex needs and spend more time in hospital, meaning that there is close competition for bed space and NHS spending goes up. Having more elderly patients means that medical staff must consider ethical questions of prolonging life versus quality of life.

Rachel also noted that every year more people will continue to use the internet to get medical information. This presents new challenges as families can find themselves fixated on information that is not relevant to the particular patient’s condition. In general, there is concern in the UK about underfunding of the NHS and staff shortages, with some right-wing politicians believing this means that some areas of the service should be privatised. However, this view is receiving staunch resistance from the British public. In a time of tumultuous political change, the NHS will no doubt continue to feature centre stage in discussions about Britain’s future.

Fact box

● The NHS in England deals with over 1 million patients every 36 hours.

● The NHS currently employs more than 1.5 million people, making it the UK’s biggest employer and putting it in the top five of the world’s largest workforces. This includes over 300,000 nurses and over 100,000 doctors.

● When it was launched, the NHS had a budget of 437 million pounds (roughly 15 billion pounds at today’s value). Last year, the NHS budget was around 116.4 billion pounds.

● The only services not completely free under the NHS are dentistry, eye tests and prescriptions. UK patients pay a fixed fee of £8.60 for their prescription, regardless of how much the NHS had to pay for the medicine in the first place. Certain people are exempt from this charge and can get their prescriptions completely free, these include students under 18, adults over 60, pregnant women (or those with a baby under 12 months old), those with disabilities and those who are unemployed.

● In 2014, the NHS was ranked as the most impressive healthcare system by the Commonwealth Fund (in comparison with the healthcare systems of ten other countries: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, and the USA).

● The 2012 London Olympics opening ceremony included a tribute to the NHS, with performers coming from the NHS or local schools. The creator of the show, Danny Boyle, said of the NHS “it’s something that we are really proud of. It celebrates something unique about this country”.


Two generations of nurses, united by caring

In 1948 the Labour government in Britain founded the National Health Service (NHS) based on three main principles: it must meet everyone’s needs, it must be free at the point of delivery, and it must be based on need. The NHS has changed in many ways since its beginning, but its core principles remain the same and UK residents can still see a doctor or have hospital treatment free of charge.

Private healthcare is also available in the UK, but most people prefer the NHS, even those that are better off. My grandfather, for example, had private health insurance through his work, but he hardly ever used it.

One of the things that has changed dramatically about the NHS is its nurses. In its early days, trainee nurses lived on-site in nurses’ quarters with the other trainees, and there were very strict rules enforced by the ward sister, the head nurse. The types of tasks they performed included changing dressings and helping patients recover after an operation, sometimes in their homes. They would spend a lot of time with patients and often offered them a cigarette to help calm the nerves. Today, that would be unheard of !

Nowadays nurse training is much more intense. Nurses today spend much less time with patients and undertake tasks that were done by doctors in the past, such as taking blood tests and administering injections. The NHS currently suffers from underfunding and staff shortages, but continues to offer excellent quality service.



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Two generations of nurses, united by caring



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